What is a lateral extra-articular tenodesis and why would I need one?

It's an additional soft-tissue procedure on the outer side of the knee, done at the same time as ACL reconstruction, that controls rotational instability the ACL graft doesn't fully address on its own. Dr. Raffo adds it to high-risk pivoting athletes because a large randomized trial found it cut graft rupture roughly in half — from 11% to 4% at 2 years (Getgood et al., AJSM 2020).

How much does adding a lateral tenodesis actually reduce my risk of re-tearing my ACL?

In the STABILITY randomized trial of 618 high-risk patients, graft rupture at 2 years fell from 11% without the procedure to 4% with it added, and overall clinical failure — including rotational instability, not just full rupture — fell from 40% to 25% (Getgood et al., AJSM 2020). In revision ACL surgery, a pooled analysis found failure rates of 11.7% without a lateral procedure versus 5.6% with one (Grassi et al., AJSM 2024).

Does a lateral tenodesis cause arthritis later in life?

This is genuinely unsettled. A 2025 meta-analysis found LET associated with higher odds of lateral compartment osteoarthritis at a mean of 13.1 years (odds ratio 2.87 to 4.38), but the same study found LET protective against osteoarthritis in knees that had already lost their meniscus (Gkekas et al., JBJS 2025). An earlier 2017 review found no clear evidence that LET increases arthritis and attributed late arthritis mainly to meniscal damage present at the original surgery (Devitt et al., KSSTA 2017). Dr. Raffo discusses this open question directly with patients rather than picking one side of the literature.

Will adding a lateral tenodesis make my recovery longer or more painful?

You can expect somewhat more pain at the outer knee incision in the first 3 to 6 months — this was measurable in the STABILITY trial — but there was no difference in pain or activity level by 2 years, and no difference in range of motion between patients who did and did not have LET added (Getgood et al., AJSM 2020; Heard et al., J ISAKOS 2023).

Does everyone getting ACL surgery need a lateral tenodesis?

No. Dr. Raffo adds it selectively, based on documented risk factors such as high-grade pivot shift, generalized ligamentous laxity, young age with a hamstring graft, or revision surgery. A 2024 expert consensus of 53 surgeons grades these indications from "strongly recommended" to "should be considered," and patients outside those groups often don't need it (Saithna, Geeslin, Sonnery-Cottet, Arthroscopy 2025).

Does the hardware from a lateral tenodesis ever need to come out?

Occasionally. In a 2026 meta-analysis of 17 studies, hardware removal was needed in about 0.82% of LET cases (Johnson et al., AJSM 2026). In the STABILITY trial, 10 patients who had LET needed hardware removal compared with 4 who had ACL reconstruction alone (Heard et al., J ISAKOS 2023).

Is a lateral tenodesis more important in revision ACL surgery than the first time?

Often, yes. Expert consensus recommends adding a lateral procedure in revision ACL reconstruction, and pooled data show failure rates falling from 11.7% to 5.6% when a lateral procedure is added in that setting (Grassi et al., AJSM 2024; Saithna, Geeslin, Sonnery-Cottet, Arthroscopy 2025). See the revision ACL reconstruction page for more detail.

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Why Add a Lateral Tenodesis to ACL Reconstruction?

Q: Is there long-term data on how well the STABILITY trial's results hold up?

Not yet in peer-reviewed form. STABILITY's 2-year results are well established, but a peer-reviewed 5-year outcome paper has not been published. The only longer-term data come from a single-center subset of 82 of the trial's 618 patients, reported in a university thesis (Inch, Western University ETD, 2022). A larger successor trial, STABILITY 2, with 1,236 patients, is still enrolling (ClinicalTrials.gov NCT03935750).

Dr. Raffo adds a lateral extra-articular tenodesis to ACL reconstruction in high-risk pivoting knees because it substantially cuts graft rupture and clinical failure, with an honest look at the unresolved OA question.

High volume — Dr. Raffo’s own characterization

Overview

A lateral extra-articular tenodesis (LET) is a soft-tissue procedure on the outer side of the knee, added to ACL reconstruction to control rotational instability that the ACL graft alone does not fully address. Dr. Raffo, who performs a high volume of ACL reconstruction for patients across Bethesda, Germantown, and the rest of Montgomery County, adds an LET to most high-risk pivoting athletes because randomized trial data show a large reduction in both graft rupture and overall clinical failure.

Who this is for

Young, active patients receiving a hamstring autograft, especially those returning to pivoting or cutting sports, are strongly indicated for LET by expert consensus (Saithna, Geeslin, Sonnery-Cottet, Arthroscopy 2025).
Patients with a grade III pivot shift, generalized ligamentous laxity with knee hyperextension, or skeletal immaturity are also strongly indicated for LET (Saithna, Geeslin, Sonnery-Cottet, Arthroscopy 2025).
Revision ACL reconstruction and chronic ACL deficiency are recommended indications (Saithna, Geeslin, Sonnery-Cottet, Arthroscopy 2025).
Young, active patients receiving a bone-patellar tendon-bone or quadriceps tendon graft, pivoting-sport athletes generally, grade 3 Lachman, posterior tibial slope greater than 12 degrees, and a history of contralateral ACL injury fall into the "should be considered" tier — a real but softer indication (Saithna, Geeslin, Sonnery-Cottet, Arthroscopy 2025).
Patients with a normal pivot shift, no hyperextension, low-demand activity goals, or significant pre-existing lateral compartment arthritis are generally not candidates — the added surgical time and the unresolved long-term joint question are harder to justify without a clear risk factor.

How I approach it

I add a lateral extra-articular tenodesis to essentially every high-risk pivoting athlete because the reduction in graft failure is too large to leave on the table. In the STABILITY trial — a 9-center randomized trial of 618 patients aged 14 to 25 at high risk of graft failure — clinical failure at 2 years, a composite of rotatory laxity or graft rupture, occurred in 40% of patients who had ACL reconstruction alone versus 25% of those who also had an LET, for a number needed to treat of just 6.7 (Getgood et al., AJSM 2020). Graft rupture specifically fell from 11% to 4%, a number needed to treat of 14.3 (Getgood et al., AJSM 2020). In the revision setting the effect is just as large: a pooled analysis of 8 studies found failure rates of 11.7% without a lateral procedure versus 5.6% with one added (Grassi et al., AJSM 2024). Those numbers are why I don't treat LET as optional in a young pivoting athlete or in revision surgery — a dramatic decrease in retears is exactly what this procedure delivers, and I think a patient facing a 1-in-4 or 1-in-10 chance of blowing out a second graft deserves to have that risk cut in roughly half or more.

I'm also direct about what LET does not settle. STABILITY has not yet published a peer-reviewed 5-year outcome paper — the only long-term data come from a single-center subset of 82 of the trial's 618 patients, reported in a university thesis rather than a journal (Inch, Western University ETD, 2022). And the question of whether LET raises the risk of lateral compartment arthritis over the long run is genuinely unsettled — I discuss that tension with every patient, not just the retear numbers, because a decision this consequential deserves the whole picture.

The operation

LET is performed through a small separate incision on the outer side of the knee, typically using a strip of the iliotibial band left attached distally (the modified Lemaire technique) or a similar lateral graft, which is passed under the lateral collateral ligament and fixed to the femur near the ACL graft's femoral tunnel, tensioned with the knee in a specific degree of flexion and rotation. It is done in the same operative setting as the ACL reconstruction, adding time to the procedure but not requiring a separate surgery or separate recovery period. Adding LET has not been shown to increase adverse events or reduce range of motion compared with ACL reconstruction alone (Heard et al., J ISAKOS 2023).

Where Surgeons Disagree

Does LET's failure-reduction benefit outweigh its unresolved long-term arthritis risk?

Yes, for the high-risk patients described above — the near-term stability benefit is large, well-replicated, and the long-term arthritis question, while real, is not yet resolved against LET.

The STABILITY randomized trial found LET cut clinical failure from 40% to 25% and graft rupture from 11% to 4% at 2 years, with a number needed to treat of just 6.7 for clinical failure and 14.3 for graft rupture (Getgood et al., AJSM 2020). In revision ACL reconstruction, adding a lateral procedure cut failure from 11.7% to 5.6% across a pooled analysis of 342 versus 334 patients (Grassi et al., AJSM 2024). Set against that: a 2025 JBJS meta-analysis of 6 studies and 444 patients followed a mean of 13.1 years found LET was associated with significantly higher lateral compartment osteoarthritis — odds ratio 2.87 by Kellgren-Lawrence grading and 4.38 by IKDC grading — though, notably, the same analysis found LET was protective against osteoarthritis in knees that had already had a meniscectomy (Gkekas et al., JBJS 2025). A separate 2017 best-evidence synthesis had concluded the opposite — that there was insufficient evidence LET increases osteoarthritis, and that late-series arthritis was better explained by meniscal damage at the index surgery than by the tenodesis itself (Devitt et al., KSSTA 2017). A 2025 systematic review of studies with a mean 15.8-year follow-up described the radiographic OA findings across the literature as frankly "mixed" (Bouchard et al., KSSTA 2025). I weigh a well-replicated, large, near-term stability benefit against a real but genuinely contested long-term signal, and for a young pivoting athlete facing a 40% chance of clinical failure without it, I come down on the side of adding it.

Where I’d be talked out of it

I would not add an LET to a knee with a normal pivot shift, no hyperextension, and a graft type not flagged in the consensus indications — the "should be considered" tier is not the same as "strongly recommended," and I don't think the failure-reduction data justify the procedure, and its unresolved cartilage question, in every knee indiscriminately. I would also weigh it more cautiously in a patient who already has meaningful lateral compartment wear on imaging, since that is the group in whom the 2025 JBJS signal is most concerning — although paradoxically, that same analysis found LET protective in the specific subset of knees that had already lost their meniscus.

Risks and honest tradeoffs

More pain in the first 3 to 6 months. STABILITY patients who received LET reported more pain at 3 months (P=.003 to .007) and at 6 months (P=.02), with no difference in pain or activity scores beyond 6 months (Getgood et al., AJSM 2020).
Lateral compartment osteoarthritis at long-term follow-up is a genuinely open question. A 2025 meta-analysis found significantly higher odds of lateral compartment OA with LET (OR 2.87 by Kellgren-Lawrence, OR 4.38 by IKDC), while finding LET protective in meniscectomized knees (OR 3.61–6.14 favoring LET) (Gkekas et al., JBJS 2025). Earlier and more recent reviews reach different conclusions, and a 2025 review at 15.8-year mean follow-up called the picture "mixed" (Devitt et al., KSSTA 2017; Bouchard et al., KSSTA 2025).
No published peer-reviewed 5-year STABILITY outcome data exist. The only long-term STABILITY data are from a single-center subset of 82 patients, reported in a thesis and conference abstracts, not a peer-reviewed 5-year paper (Inch, Western University ETD, 2022). The successor trial, STABILITY 2, is still enrolling (ClinicalTrials.gov NCT03935750).
Hardware removal. In a 2026 meta-analysis of 17 studies, LET hardware required removal in 0.82% of cases (Johnson et al., AJSM 2026); in STABILITY, 10 LET patients versus 4 ACLR-alone patients needed hardware removal (Heard et al., J ISAKOS 2023).
Surgical-site pain in revision surgery can be substantial. One series included in a larger review reported surgical-site pain in 72.1% of tenodesis patients versus 15.9% without, lasting a median of 3.2 versus 1.2 months, even though the same series showed a large failure-rate benefit (Grassi et al., AJSM 2024).
No increase in overall adverse events or motion loss. STABILITY found no difference in range of motion between groups, and overall complication rates in ALL-reconstruction meta-analysis did not differ between groups (13.29% vs 12.8%, P=.21) (Heard et al., J ISAKOS 2023; Knee Surg Relat Res 2026).

Recovery and rehabilitation

Recovery after ACL reconstruction with LET follows the same criteria-based framework as ACL reconstruction alone, since STABILITY found no difference in range of motion between the two groups. Patients should expect somewhat more discomfort in the first 3 to 6 months at the lateral incision site, which resolves without a measurable difference in activity scores by 2 years.

Weeks 0–2: Early motion and weightbearing; more soft-tissue discomfort at the lateral incision than with ACL reconstruction alone, typically manageable with standard postoperative pain control.
Weeks 3–6: Progressive closed-chain quadriceps strengthening, as with any ACL reconstruction.
Months 3–6: The period of measurably increased pain reported in STABILITY resolves; sport-specific agility work begins later in this window.
Months 6–9: Formal strength and hop testing.
Month 9 and beyond: Return to pivoting sport only after passing a strength and hop-test battery — the same threshold used for ACL reconstruction without LET (Grindem et al., BJSM 2016).

Weeks 0–2
Early motion and weightbearing.
more soft-tissue discomfort at the lateral incision than with ACL reconstruction alone, typically manageable with standard postoperative pain control.
Weeks 3–6
Progressive closed-chain quadriceps strengthening, as with any ACL reconstruction.
Months 3–6
The period of measurably increased pain reported in STABILITY resolves; sport-specific agility work begins later in this window.
Months 6–9
Formal strength and hop testing.
Month 9 and beyond
Return to pivoting sport only after passing a strength and hop-test battery.
the same threshold used for ACL reconstruction without LET (Grindem et al., BJSM 2016).

Alternatives I considered

For patients who fall into the "should be considered" rather than "strongly recommended" tier of the consensus indications, I discuss proceeding with ACL reconstruction alone and accepting a higher, but not certain, chance of graft failure, particularly when the patient has a normal pivot shift and no hyperextension. A 2020 meta-analysis found no difference in patient-reported functional outcomes between ACL reconstruction alone and with an anterolateral procedure, which means the decision is really about failure risk and long-term joint tradeoffs, not day-to-day function (Arthroscopy 2020). Full graft-choice discussion is on the ACL reconstruction hub.

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Medically reviewed by Christopher S. Raffo, MD · August 5, 2026